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Between-centre differences and treatment effects in randomized controlled trials: A case study in traumatic brain injury

Hester F Lingsma1*, Bob Roozenbeek12, Pablo Perel3, Ian Roberts3, Andrew IR Maas2 and Ewout W Steyerberg1

Author Affiliations

1 Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands

2 Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650 Edegem, Belgium

3 Epidemiology and Population Health Department, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK

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Trials 2011, 12:201  doi:10.1186/1745-6215-12-201

Published: 25 August 2011



In Traumatic Brain Injury (TBI), large between-centre differences in outcome exist and many clinicians believe that such differences influence estimation of the treatment effect in randomized controlled trial (RCTs). The aim of this study was to assess the influence of between-centre differences in outcome on the estimated treatment effect in a large RCT in TBI.


We used data from the MRC CRASH trial on the efficacy of corticosteroid infusion in patients with TBI. We analyzed the effect of the treatment on 14 day mortality with fixed effect logistic regression. Next we used random effects logistic regression with a random intercept to estimate the treatment effect taking into account between-centre differences in outcome. Between-centre differences in outcome were expressed with a 95% range of odds ratios (OR) for centres compared to the average, based on the variance of the random effects (tau2). A random effects logistic regression model with random slopes was used to allow the treatment effect to vary by centre. The variation in treatment effect between the centres was expressed in a 95% range of the estimated treatment ORs.


In 9978 patients from 237 centres, 14-day mortality was 19.5%. Mortality was higher in the treatment group (OR = 1.22, p = 0.00010). Using a random effects model showed large between-centre differences in outcome (95% range of centre effects: 0.27- 3.71), but did not substantially change the estimated treatment effect (OR = 1.24, p = 0.00003). There was limited, although statistically significant, between-centre variation in the treatment effect (OR = 1.22, 95% treatment OR range: 1.17-1.26).


Large between-centre differences in outcome do not necessarily affect the estimated treatment effect in RCTs, in contrast to current beliefs in the clinical area of TBI.